Molar pregnancy Flashcards

1
Q

What is gestational trophoblastic disease (GTD)?

A

used to describe group of pregnancy-related tumours; split into pre-malignant and malignant conditions

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2
Q

What are the 2 groups of types of gestational trophoblastic disease?

A
  1. Pre-malignant conditions e.g. partial molar pregnancy and complete molar pregnancy
  2. Malignant conditions e.g. invasive mole, choriocarcinoma, placental trophoblastic site tumour and epithelioid trophoblastic tumour
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3
Q

Of the 2 types of gestational trophoblastic disease, which type is more common?

A

Pre-malignant conditions more common than malignant conditions

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4
Q

What are 2 types of pre-malignant GTD?

A
  1. Partial molar pregnancy
  2. Complete molar pregnancy
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5
Q

What are 4 malignant forms of GTD?

A
  1. Invasive mole
  2. Choriocarcinoma
  3. Placental trophoblastic site tumour
  4. Epithelioid trophoblastic tumour
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6
Q

What, broadly speaking, is the cause of molar pregnancies?

A

abnormality in chromosomal number during fertilisation

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7
Q

What is the cause of partial molar pregnancy?

A

one ovum with 23 chromosomes is fertilised by two sperm, each with 23 chromosomes - results in triploidy (cells with 69 chromosomes)

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8
Q

If a partial mole exists with a viable fetus, what is going on genetically in the cells of the fetus and placenta?

A

the fetus and placenta are usually triploid, however mosaicism can exist where the fetus has a normal karyotype and triploidy is confined to the placenta

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9
Q

What is the cause of complete molar pregnancy?

A

one ovum without any chromosomes is fertilised by one sperm which duplicates, or (less commonly) two different sperm, leading to 46 chromosomes of paternal origin alone

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10
Q

How do invasive moles differ from benign molar tumours?

A

they invade into the uterine myometrium and disseminate around the body. benign molar pregnancy can become malignant

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11
Q

What is choriocarcinoma?

A

malignancy of the trophoblastic cells of the placenta, commonly co-exists with a molar pregnancy

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12
Q

Where does a choriocarcinoma characteristically metastasise to?

A

lungs

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13
Q

What is a placental site trophoblastic tumours?

A

malignancy of the intermediate trophoblasts which are normally responsible for anchoring the placenta to the uterus

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14
Q

What are 3 things that a placental site trophoblastic tumours can arise from and which is most common?

A
  1. Normal pregnancy → most common
  2. Molar pregnancy
  3. Miscarriage
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15
Q

What is an epithelioid trophoblastic tumour?

A

malignancy of the trophoblastic placental cells, which can be very difficult to distinguish from choriocarcinoma

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16
Q

What type of cancer does an epithelioid trophoblastic tumour mimic the cytological features of?

A

squamous cell carcinoma

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17
Q

What are 4 major risk factors for gestational trophoblastic disease?

A
  1. Maternal age <20 or >35
  2. Previous gestational trophoblastic disease (risk is not decreased by a change of partner)
  3. Previous miscarriage
  4. Use of oral contraceptive pill
18
Q

Is the risk of gestational trophoblastic disease that is associated with previous GTD decreased by a change of partner?

A

no

19
Q

What are 5 earlier clinical features of molar pregnancies?

A
  1. Vaginal bleeding
  2. Abdominal pain in early pregnancy
  3. Larger uterus than expected for gestation
  4. Soft, boggy uterus
  5. Molar vesicles can occasionally shed per vagina
20
Q

If molar pregnancy is undiagnosed, what are 3 late clinical features?

A
  1. Hyperemesis
  2. Hyperthyroidism
  3. Anaemia
21
Q

Why is excessive hyperemesis thought to occur with molar pregnancy?

A

increased titre of beta hCG which is thought to be linked to nausea in pregnancy

22
Q

What causes hyperthyroidism in late molar pregnancy?

A

gestational thyrotoxicosis due to stimulation of thyroid by high HCG levels (acts like TSH)

23
Q

What are the 4 most common investigations in the assessment of suspected gestational trophoblastic disease?

A
  1. Urine beta-hCG
  2. Blood beta-hCG leels
  3. Ultrasound scan
  4. Histological examination of the products of conception post-treatment
24
Q

When will the urine beta-hCG remain positive following delivery?

A

for a number of weeks (usually say by 4 weeks it should be negative)

25
Q

What will blood beta-hCG levels show in GTD?

A

markedly elevated at diagnosis (also used in monitoring of GTD)

26
Q

What will an ultrasound scan show for a complete mole?

A

granular or snowstorm appearance with central heterogeneous mass and surrounding multiple cystic areas/vesicles

27
Q

What type of molar pregnancy may show a granular/snowstorm appearance on ultrasound?

A

complete molar pregnancy only

28
Q

When is histological examination of the products of conception performed to help diagnose gestational trophoblastic disease?

A

performed post-treatment on molar pregnancies, and all non-viable pregnancies to confirm diagnosis and plan follow-up

29
Q

What are 2 reasons why histological examination of the products of conception are performed in suspected GTD?

A
  1. Confirm diagnosis
  2. Plan follow up
30
Q

If metastatic spread is suspected in GTD, what additional investigations are required?

A

staging investigations: MRI, CT chest-abdomen-pelvic and/or pelvic ultrasound

31
Q

Who must all women diagnosed with GTD in the UK be registered with and why?

A

a national GTD centre, for follow-up and monitoring in future pregnancies (in Sheffield, Charing Cross, Dundee)

32
Q

What guides the specific management in gestational trophoblastic disease?

A

dependent on the exact type of tumour

33
Q

What are 4 possible aspects of the management of molar pregnancy, as well as registration with a national centre?

A
  1. Suction currettage for complete moles and non-viable partial moles
  2. Medical evacuation recommended if partial mole is of greater gestation with fetal development and not conducive to surgical evacuation
  3. In all cases, anti-D prophylaxis post-evacuation is mother is rhesus negative
34
Q

What is the recommended management for complete moles and non-viable partial moles?

A

suction curettage

35
Q

What is the recommended management for partial moles of greater gestation with getal development and not conducive to surgery?

A

medical evacuation, urinary beta-hCG measurement 3 weeks post-treatment

36
Q

What should always be combined with medical evacuation of molar pregnancy?

A

urinary beta-hCG measurement 3 post-treatment

37
Q

What is the theoretical risk of medical management with oxytocic agents for complete moles and non-viable partial moles?

A

Theoretical risk of embolisation of the trophoblastic tissue

38
Q

What prophylaxis may be needed for all types of evacuation of molar pregnancies?

A

anti-D prophylaxis may be needed

39
Q

What treatment may be needed if evacuation of molar pregnancy does not lead to a fall in beta-hCG?

A

chemotherapy

40
Q

When should a patient with GTD be referred to a specialist GTD treatment centre? 2 situations

A
  1. Malignant gestational trophoblastic disease
  2. Partial/complete mole that has not resolved
41
Q

What is the mainstay of treatment for malignant GTD or partial/complete moles that have not resolved with initial treatment?

A

single or multiple agent chemotherapy ± surgery